Late Reoperation for Proximal Aortic Complication in a Marfan Patient Following Ascending Aortic Grafting

We report a case of a female patient with Marfan syndrome who suffered a type A acute aortic dissection eleven years ago. At that time she underwent supracoronary ascending aortic grafting and resuspension of the incompetent aortic valve. Recently this patient presented to us with uncontrolled hypertension and a transthoracic echocardiographic study revealed severe dilatation of the sinuses of Valsalva. She required reoperation and a Bentall procedure was performed. Surgical treatment of the Marfan syndrome is discussed

Catheter Ablation of Two Accessory Pathways in Elusive Ebstein's Anomaly: Procedure Facilitation With Use of a Long Vascular Sheath

A 17-year-old adolescent presenting with multiple episodes of palpitations over the previous 9 months refractory to antiarrhythmic drug therapy and with manifest preexcitation on the 12-lead surface electrocardiogram (type B Wolff-Parkinson-White syndrome) was referred for radiofrequency (RF) catheter ablation. The initial echocardiographic evaluation was reported normal. The first procedure was tedious and prolonged, hampered by the occurrence of mechanical block in the antegrade conduction of the accessory pathway (loss of preexcitation) for the duration of the procedure. There was only retrograde conduction noted via a right lateral accessory pathway and inducible atrioventricular tachycardia with the participation of this concealed pathway, which was successfully ablated after the delivery of 9 radiofrequency energy applications (...excerpt

Right Ventricular Outflow Tract Obstruction in a Middle Aged Man with Right-Sided Aortic Arch

Congenital diseases causing an obstruction of the right ventricular outflow tract are difficult to precisely diagnose, especially in elderly patients. We report a case of a 49-year-old man who presented to our hospital with longstanding shortness of breath on exertion. He was finally diagnosed as right ventricular outflow tract obstruction and referred for surgical correction. The patient had a history of descending aorta dissection which was treated by thoracic stent grafting. By that time right-sided aortic arch was diagnosed. The coexistence of right ventricular outflow tract obstraction and right sided aortic arch in the same patient is very rare, to the best of our knowledge

Matrix metalloproteinases and tissue inhibitors of metalloproteinases during coronary artery bypass grafting with or without cardiopulmonary bypass

BACKROUND: The use of the Cardiopulmonary Bypass (CPB) during coronary bypass surgery may be responsible for a series of potentially dangerous consequences with which the Systemic Inflammatory Response Syndrome (SIRS) and the Ischemia-Reperfusion Injury are associated. The development of SIRS and Ischemia-Reperfusion injury during CPB have been found to be associated with the activation of Matrix Metalloproteinases (MMPs). Coronary surgery without CPB is based on the argument that, eliminating CPB significantly, decreases the secretion of proinflammatory substances that stimulate the SIRS syndrome, and reduces the duration of ischemia which is responsible for Ischemia-Reperfusion injury.The purpose of this prospective, randomized study was the identification of metalloproteinases MMP-9 and MMP-13 in patients undergoing CABG with and without CPB and the study of concurrent changes of TIMP-1 and TIMP-4.METHODS: The current prospective, randomized study included 40 patients who underwent elective coronary bypass. The inclusion and exclusion criteria of the study were determined based on a thorough literature review. During their entrance in the study, the patients were randomized into two groups, and post-randomization analysis of the two groups showed they have similar demographic characteristics. Group A patients (CCABG) underwent coronary bypass under CPB, while Group B patients (OPCAB) underwent off-pump coronary bypass without CPB. Blood was drawn from the central venous catheter of all patients, in order to measure plasma levels of MMP-9, MMP-13, TIMP-1 and TIMP-4 at four specific timepoints during the surgery. RESULTS: There was no association between the pre-operative levels of MMP-9/MMP-13/TIMP-1/TIMP-4 and the surgical risk (as estimated byEuroSCORE) or the severity of the coronary artery disease (as estimatedby the number of grafts needed). Analysis of the levels of MMP-9 and TIMPs between the two groups at various timepoints showed that during CPB (CCABG) in coronary bypass surgery – which is associated with trauma due to blood contact with the CPB-circuit tubing and also Ischemia-Reperfusion injury after aortic clamp release – there is an increase of the plasma levels of MMP-9, with consequent decrease of the plasma levels of TIMP-1. These changes become evident immediately before the disconnection of the patient from the CPB circuit. After the disconnection of the patient from the CPB circuit and until the end of the operation, the MMP-9 activation ceases and its plasma level drops, but this is not associated with its endogenous suppression by TIMPs. On the other hand, in coronary bypass surgery without CPB (OPCAB) – which is associated with intermittent periods of local ischemia secondary to surgical manipulations for the performing of the peripheral anastomoses – there is no activation of MMP-9. During the subsequent reperfusion phase, there is also no activation of MMP-9.Analysis of the levels of MMP-13 shows that they do not exhibit any statistically significant change between the two groups at any of the timepoints, and there are no associated changes in TIMPs levels.CONCLUSION: In conclusion, CCABG operations involve the production and activation of MMP-9 for a significant duration of time. The association of increased MMP-9 expression with high morbidity, organ dysfunction and clinical syndromes in CCABG operations necessitates further studies.ΣKOΠΟΣ: Η εξωσωματική κυκλοφορία (Ε/Κ) στις εγχειρήσεις αορτοστεφανιαίας παράκαμψης ενοχοποιείται για μια σειρά δυνητικά επιβλαβών διεργασιών που πυροδοτούν το Σύνδρομο Συστηματικής Φλεγμονώδους Αντίδρασης (SIRS) καθώς και το τραύμα ≪Ισχαιμίας-Επαναιμάτωσης≫, καταστάσεις που μεταξύ άλλων σχετίζονται και με την ενεργοποίηση των μεταλλοπρωτεϊνασών (ΜΜΡs). Η στεφανιαία χειρουργική χωρίς Ε/Κ, μειώνει σημαντικά την πυροδότηση του συνδρόμου SIRS, αλλά και περιορίζει το τραύμα ≪Ισχαιμίας-Επαναιμάτωσης≫. Σκοπός της παρούσας μελέτης αποτέλεσε ο προσδιορισμός των επιπέδων των μεταλλοπρωτεϊνασών ΜΜΡ-9 και ΜΜΡ-13 στον ορό του αίματος σε ασθενείς που υποβάλλονται σε εγχειρήσεις αορτοστεφανιαίας παράκαμψης με και χωρίς Ε/Κ, καθώς και η μελέτη των ταυτόχρονων μεταβολών των φυσικών αναστολέων τους ΤΙΜΡ-1 και ΤΙΜΡ-4.ΜΕΘΟΔΟΣ: Στη παρούσα προοπτική τυχαιοποιημένη μελέτη, συμμετείχαν 40 ασθενείς που υποβλήθηκαν σε προγραμματισμένη αορτοστεφανιαία παράκαμψη. Οι ασθενείς πληρούσαν τα κριτήρια εισόδου και αποκλεισμού της μελέτης αυτής. Οι ασθενείς κατά την εισαγωγή τους τυχαιοποιήθηκαν σε δύο ομάδες, με παρόμοια δημογραφικά στοιχεία. Στην Ομάδα Α, στην οποία οι ασθενείς χειρουργήθηκαν με τη χρήση της εξωσωματικής κυκλοφορίας (CCABG) και στην Ομάδα Β, στην οποία οι ασθενείς χειρουργήθηκαν χωρίς εξωσωματική κυκλοφορία (OPCAB). Από τους ασθενείς και των δύο ομάδων λήφθηκε αίμα από τον καθετήρα της κεντρικής φλεβικής γραμμής για τον προσδιορισμό των επιπέδων των ΜΜΡ-9, ΜΜΡ-13, ΤΙΜΡ-1 και ΤΙΜΡ-4 στον ορό του αίματος σε τέσσερεις καθορισμένες χρονικές στιγμές της κάθε επέμβασης. ΑΠΟΤΕΛΕΣΜΑΤΑ: Η μελέτη των προεγχειρητικών τιμών των επιπέδων των ΜΜΡ-9,ΜΜΡ-13, ΤΙΜΡ-1 και ΤΙΜΡ-4 σε σχέση με τον καρδιοχειρουργικό κίνδυνο (εκτιμούμενο με το EuroSCORE) και τη βαρύτητα της στεφανιαίας νόσου (εκτιμουμένης με τον αριθμό των απαιτούμενων μοσχευμάτων) έδειξε ότι δεν υπάρχει καμιά συσχέτιση μεταξύ τους. Από τη μελέτη των επιπέδων της ΜMP-9 και των TIMPs στις διάφορες χρονικές φάσεις των επεμβάσεων των δύο ομάδων, συμπεραίνεται ότι στις επεμβάσεις αορτοστεφανιαίας παράκαμψης με Ε/Κ (CCABG) η επίδραση του τραύματος που προκαλείται από την επαφή του αίματος με το κύκλωμα της Ε/Κ και η επίδραση του τραύματος Ισχαιμίας /Επαναιμάτωσης έχουν σαν αποτέλεσμα την αύξηση των επιπέδων της ΜΜΡ-9 στο αίμα με συνέπεια τη μείωση των επιπέδων του ΤΙΜΡ-1, λόγω ενδογενούς προσπάθειας του οργανισμού να δεσμεύσει μέρος από την παραγόμενη ΜΜΡ-9. Οι μεταβολές αυτές γίνονται εμφανείς αμέσως πριν την αποσύνδεση του ασθενούς από το κύκλωμα της Ε/Κ. Μετά την αποσύνδεση του ασθενούς από το κύκλωμα της Ε/Κ και μέχρι το τέλος της επέμβασης, η παραγωγή της ΜΜΡ-9 σταματά, με αποτέλεσμα τη μείωση των επιπέδων της στο αίμα η οποία δεν σχετίζεται με την ενδογενή αναστολή της από τους TIMP-1 και ΤΙΜΡ-4. Αντίθετα στις επεμβάσεις αορτοστεφανιαίας παράκαμψης χωρίς Ε/Κ (ΟΡCAB), η επίδραση του τραύματος που προκαλείται από τις διακοπτόμενες φάσεις τοπικής ισχαιμίας λόγω των χειρουργικών χειρισμών, κατάτην εκτέλεση των περιφερικών αναστομώσεων, δεν προκαλεί ενεργοποίηση της ΜΜΡ-9. Κατά τη φάση επαναιμάτωσης που ακολουθεί, η επίδραση του τραύματος Επαναιμάτωσης επίσης δεν προκαλεί ενεργοποίηση της ΜΜΡ-9. Από τη μελέτη των επιπέδων της ΜMP-13 και των TIMP-1, ΤΙΜΡ-4 των δύο ομάδων, δεν παρουσιάζεται καμιά στατιστικά σημαντική μεταβολή των τιμών της ΜMP-13 στις διάφορες φάσεις των δύο τύπων επεμβάσεων, ούτε και συσχέτιση των τιμών της με τους TIMP-1 και ΤΙΜΡ-4.ΣΥΜΠΕΡΑΣΜΑΤΑ: Οι εγχειρήσεις CCABG προκαλούν αυξημένη παραγωγή της ΜΜΡ-9 για ένα ικανό χρονικό διάστημα. Για τη συσχέτιση της αυξημένης αυτής έκφρασης της ΜΜΡ-9 με υψηλή νοσηρότητα, δυσλειτουργία ζωτικών οργάνων και δυσμενή κλινικά συμβάματα σε επεμβάσεις CCABG απαιτούνται περαιτέρω έρευνες

Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: Single operator experience in 110 consecutive patients

Objective: Percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) is routinely performed under general anesthesia or deep sedation and use of transesophageal (TEE) or intracardiac echocardiography, incurring longer duration and higher cost. We have used a simplified, economical, fluoroscopy-only guided approach with local anesthesia, and herein report our data. Methods: The study includes 112 procedures in 110 patients with PFO (n = 75) or ASD (n = 35), with use of an Amplatzer occluder, heparin and prophylactic antibiotics. Balloon sizing guided ASD-device selection. All patients received aspirin and clopidogrel for 6 months, when they all underwent TEE. Results: All PFOs but one (98.7%) and all (100%) ASDs were successfully closed with only one complication (local pseudoaneurysm). At the 6-month TEE, there was no residual shunt in PFO patients, but 2 ASD patients had residual shunts. During long-term (4.3-year) follow-up, no stroke recurrence in PFO patients, and no other problems were encountered. Among 54 patients suffering from migraine, symptom relief or resolution was reported by 45 (83.3%) patients. Conclusion: Percutaneous placement of an Amplatzer occluder was safe and effective with use of local anesthesia and fluoroscopy alone. There were no recurrent strokes over >4 years. Migraine relief was reported by >80% of patients

Simplified percutaneous closure of patent foramen ovale and atrial septal defect with use of plain fluoroscopy: Single operator experience in 110 consecutive patients

Objective: Percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) is routinely performed under general anesthesia or deep sedation and use of transesophageal (TEE) or intracardiac echocardiography, incurring longer duration and higher cost. We have used a simplified, economical, fluoroscopy-only guided approach with local anesthesia, and herein report our data. Methods: The study includes 112 procedures in 110 patients with PFO (n = 75) or ASD (n = 35), with use of an Amplatzer occluder, heparin and prophylactic antibiotics. Balloon sizing guided ASD-device selection. All patients received aspirin and clopidogrel for 6 months, when they all underwent TEE. Results: All PFOs but one (98.7%) and all (100%) ASDs were successfully closed with only one complication (local pseudoaneurysm). At the 6-month TEE, there was no residual shunt in PFO patients, but 2 ASD patients had residual shunts. During long-term (4.3-year) follow-up, no stroke recurrence in PFO patients, and no other problems were encountered. Among 54 patients suffering from migraine, symptom relief or resolution was reported by 45 (83.3%) patients. Conclusion: Percutaneous placement of an Amplatzer occluder was safe and effective with use of local anesthesia and fluoroscopy alone. There were no recurrent strokes over >4 years. Migraine relief was reported by >80% of patients. (C) 2017 Published by Elsevier B.V. on behalf of Cardiological Society of India

Serum levels of matrix metalloproteinases -1,-2,-3 and -9 in thoracic aortic diseases and acute myocardial ischemia

<p>Abstract</p> <p>Background</p> <p>Matrix metalloproteinases (MMPs) constitute a family of zinc-dependent proteases (endopeptidases) whose catalytic action is the degradation of the extracellular matrix components. In addition, they play the major role in the degradation of collagen and in the process of tissue remodeling. The present clinical study investigated blood serum levels of metalloproteinases- 1, -2, -3 and -9 in patients with acute and chronic aortic dissection, thoracic aortic aneurysm and acute myocardial ischemia compared to healthy individuals.</p> <p>Methods</p> <p>The blood serum levels of MMP-1, -2, -3 and -9 were calculated in 31 patients with acute aortic dissection, 18 patients with chronic aortic dissection, 18 patients with aortic aneurysm and in 13 patients with acute myocardial ischemia, as well as in 15 healthy individuals who served as the control group. Serum MMP levels were measured by using an ELISA technique.</p> <p>Results</p> <p>There were significantly higher levels of MMP-3 in patients with acute myocardial ischemia as compared to acute aortic dissection (17.33 ± 2.03 ng/ml versus 12.92 ± 1.01 ng/ml, p < 0.05). Significantly lower levels of MMP-1 were found in healthy controls compared to all groups of patients (1.1 ± 0.38 ng/ml versus 2.97 ± 0.68 in acute aortic dissection, 3.09 ± 0.98 in chronic dissection, 3.16 ± 0.51 in thoracic aortic aneurysm and 4.58 ± 1.04 in acute myocardial ischemia, p < 0.05). Higher levels of MMP-1 and MMP-3 were detected on males. There was a positive correlation with increasing age (r = 0.38, p < 0.05). In patients operated for acute type A aortic dissection, the levels of MMP-1, MMP-3 and MMP-9 increased immediately after surgery, while the levels of MMP-2 decrease. At 24 hours postoperatively, levels of MMP -1, -2 and -9 are almost equal to the preoperative ones.</p> <p>Conclusion</p> <p>Measurement of serum MMP levels in thoracic aortic disease and acute myocardial ischemia is a simple and relatively rapid laboratory test that could be used as a biochemical indicator of aortic disease or acute myocardial ischemia, when evaluated in combination with imaging techniques.</p